[janfrn]

Our unit is being pushed to begin providing CRRT. In the last three years or so, we have only had an average of four patients each year who required it. In the past we have provided all PICU care and had either a dialysis nurse or a nurse from the adult ICU run the equipment, but are being told this practice is no longer viable due to staffing shortages (which we are also experiencing). We have a number of concerns about getting started on this path. For example, we have just emerged from under the Pediatric Cardiac Inquest, the longest medical inquest in Canadian history; one of the major points made by the justice in the report was that our hospital did not perform enough cases to maintain skills. We're worried that this will be the case with CRRT. How many cases would be considered enough? One of our CRRT patients last year was an infant; in a 24 hour period we went through 14 filter sets and 7 units of blood before he died. Can we justify this kind of equipment usage? We understand that the learning curve will be fairly steep; how can we provide adequate staff to allow 2 nurses to 1 patient when some days we have to divert patients out of province because we don't have staff to care for them? I'd appreciate hearing about how other units are doing CRRT...

[Jolie]

OK, here comes a dumb question...What is CRRT?

[janfrn]

CRRT is continuous renal replacement therapy. In some areas it has been called continuous venovenous hemofiltration (CVVH); it can remove excess fluid volume, filter out waste products and/or dialyse a patient with multiple organ dysfunction syndrome, drug ingestion or other critical illnesses.

[Jolie]

OK, now that I know what you're talking about, I share your concern. On very rare occasions, we had babies on hemofiltration in our NICU. We had 1 NICU staff nurse who was skilled in this from a former job, and she practically lived in the unit when we had a baby receiving this treatment. Otherwise, a nephrology nurse would come in and assist us.

It is a complicated set-up, and the care of these babies is very complex. They deserve to have an expert caring for them. Personally I found peritoneal dialysis much easier to understand and manage.

No offense to your staff, but I suspect that the quality of care would be better and the risk of complications would be much lower if you continue to have expert nurses provide this care. It is just not possible to become proficient with so few patients per year.

[janfrn]

We feel exactly the same way! Our kids deserve to have the best care available... and we don't think that in this case, we're it! Maybe someday we will have the necessary level of expertise, but I wouldn't want my child to be one of our "practice" patients. The nephrologists live in a fairy tale world where nurses are a dime a dozen, and the chief thinks we should all agree to be on call for CRRT. Only problem is that our unit does not have a union-approved standby clause, and we aren't going to get one just for CRRT, since "being on call" in our facility has money tied to it... Oh well, we'll see what happens. Hopefully nobody ends up worse off.

[ShelleyRN]

We too have begun having the staff RNs learn CRRT. I work in a Pediatric cardiac ICU. We have used it only once in the past two years that I can even think of. We recently had our one case, and although everyone was leary at first since we hadn't done it since the class, the child was safely on it for 3 days without any mishaps. We basically retrained at shift change the RN ocming on. We did staff it as a bedside RN and a CRRT RN since the patient was so critically ill.
Shelley

[blueinplaid]

CVVH was done on our unit. We had a dialysis team that set up the machine initially, and would change the bags, tubing etc. i believe every 24 hr. I felt comfortable because there was a dialysis nurse on call if there was an issue that could not be resolved. She/he was at home, so usually it was a talk through thing. We had inservices for CVVH about once a year and there was always an experienced staff member on that was available to help . I felt very comfortable with doing CVVH with the dialysis team from the hospital coming every 24 hrs and handling the intricacies. That might be an option for your staff.

[KR]

Hello all. I have worked in only adult ICU's, CVICU, CCU, MICU, SICU and at 5/6 hospitals we have some specially trained ICU nurses to do CRRT. I happen to be one of those nurses. We do everything from starting up the PRISMA machine, priming the tubing, hooking up the patient, changing the kidney if it clots, routine changes, and disconnecting therapy. The only thing we do not do is TPA the dialysis catheters if they clot. Hope this helps. Kimberly

[UK2USA]

I work on a PICU unit in the UK. We run CRRT (CVVH) on the unit whenever we need to. The nurse: patient ratio is 1:1, we don't usually need to increase this. If you are running through filters at such a rate it would suggest that either you are running to high a filtration fraction (and pushing the filter beyond its limits) or that the filter set has not been adequately heparinised. What were your 'activated clotting times'?.

Using CVVH on our unit is not something that all our nurses partake in, there is a study period (2 days for new starters, 1 week for those wishing to complete a level 3 module for BSc), after which a competency log must be completed before a nurse can look after one of these patients.

If you are concerned with the training that your staff has had, send me a message with your email and I will post some competency/training stuff to you.

[davnmf]

Hello there. I work at PICU that does CRRT quite frequently. Sometimes we go in spurts where we have 5 kids at one time on it and other times it'll be months before we get a pt that requires that kind of therapy. The only education that is offered to take care of these pts is a 4 hour class that is just about how the machine works, the basic things you need to know about the machine, how it works, and the kinds of pts that need it. Then there is an 8 hour class that goes more in detail where you learn how to set the machine up. These classes are only offered twice a year and you are not required to take them before you can take care of a pt w/ CRRT (although that rarely happens). The PICU bedside nurse pretty much does everything. The ICU fellow must be present when setting up or changing a circuit and a nephrologist is always there when initiating the therapy. If a circuit stops working for whatever reason the PICU nurse can stop the therapy w/o nephrology being present. If the nurse and nephrologist are comfortable, the PICU RN can setup and restart therapy along w/ ICU fellow alone. There is always a nephrologist on-call to adjust rates and fluids. Now that we use Calcium and Citrate instead of heparin, filters rarely clot off, even after 3 days but there are some instances where it occurs. I know this is a long reply, I hope it helps.